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During our recent focus group of age 62+ individuals, we discovered that unanimously they wished to have been better educated on Medicare from their group health benefits coordinator. When a beneficiary is part of a small group or business, the office manager can wear many hats and act as the benefits coordinator with little knowledge. On the other hand, a beneficiary of a larger group can have an assigned Human Resources Director that focuses on this area that still is not Medicare knowledgeable. As an agent, this is a huge area of opportunity to be a resource and obtain potential clients.

Grab their attention by saving the group money by educating the Medicare eligible individuals how they can enrich their health coverage and potentially save money by coming off the group plan and enrolling into Medicare. Often times, this can be the group owner themselves paying more monthly to stay on the group than they would on an individual Medicare policy.

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Your total out-of pocket drug spending (TrOOP) moves with you when you move to another Medicare Part D plan.

It can become confusing what or whose spending costs towards your TrOOP during each stage. Especially now more than ever, which tier exemptions not applying to the deductible and the inflation reduction act.

More from the Centers for Medicare and Medicaid Services (CMS) . . .

"Part D rules [42 CFR §423.104(d)] require sponsors to track the beneficiary’s TrOOP and correctly apply these costs to the TrOOP limit in order to provide enrollees the catastrophic level of coverage at the appropriate time. The TrOOP threshold is calculated on an annual basis and must be transferred between Part D sponsors if a beneficiary disenrolls and re-enrolls at any time before the end of a coverage year or whenever a Part D plan other than the plan of record has paid. Sponsor collection, and transfer if appropriate, of the TrOOP and gross covered drug spending balances are essential for sponsors to correctly manage the Part D benefit.". (page 36)

Learn more: https://q1medicare.com/faq/FAQ.php?cat=Changing-Medicare-Part-D-Plans&category_id=10

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What happens to your maximum out-of-pocket (MOOP) if you change plans throughout the year in the Open Enrollment Period (OEP) or from a life qualifying event that gives you a Special Enrollment Period (SEP)?

Your out-of-pocket expenses from your Part A & B of coverage towards your new plan’s MOOP limit will follow you if you change plans.

As noted by the Centers for Medicare and Medicaid Services (CMS) in the Medicare plan manuals:

"During a contract year, when an enrollee switches to another [Medicare Advantage] plan of the same type (for example, from one HMO to another HMO) offered by the plan, his/her accumulated annual contribution toward the annual MOOP limit in the previous plan to date is to be counted towards his/her MOOP limit in the new MA plan. As applicable, this transfer of MOOP applies to both in-network and out-of-network MOOP."

However, CMS does provide some flexibility so companies can allow your MOOP to transfer between Medicare Advantage plans even when the plans are not similar (for example, you were in an Aetna HMO and join an Aetna PPO).  The Medicare Advantage plan manual continues on to note:

"Additionally, MA [Medicare Advantage] plans may extend the transferability of the enrollee’s contribution toward his/her annual MOOP so that it applies to an enrollee’s transfer during the contract year to any MA plan type offered by the MAO [Medicare Advantage Organization].  For example, if an enrollee makes a mid-year change to move from an HMO to a PPO offered by the same MAO, his/her current contribution toward the MOOP limit may follow the enrollee and be counted towards the MOOP limit in the PPO.  This allows those enrollees who are eligible to make mid-year plan changes to freely select among the diverse MA plan options offered by an MAO."